MO-9541_40974_CA_UST-61_20180327_24-Hour Release and UST Leak Reporting Form

lST=G'1
24-Hou0" Release and UST
For Releases This form should be completed and submitted to the UST Section's regional office fallowing a known or suspected release from
an underground storage tank (UST) system. This farm is required to be submitted within 24 hours of discovery of a known or
in NC suspected release
(DWM USE ONLY)
Suspected Contamination? (Y/N) ___ __
Facility ID Number _
Incident # Risk (H,I,L,U) _
Confirmed GW Contamination? (Y/N) ___jj
Date Leak Discovered _y/�%lV
Received On _ _ Received By ______
Confirrnod Soil Contamination ?(Y/N) __ t
Con'o - ercia __/____'__
Reported by (circle one): Phone, Fax or Ropon
Samples Taken?(Y/N) __�
Rog on -regulated ________
-
Region
Free Product? (YIN) N___ If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: ^
II • \eSr \�,�,.n
[T
Address: 3 S Zo C'� Q t'
County: � ;kn
�QLO
City/Town: L\ , I Zip Code: O
Rogional Office (circle one): Asheville, res I ayetleville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (dedmaldegl a ): ^�' 1'�/ `Q" QLongitudo (neo�„��,i„�y„«a U�r '"`� d
Obtained by:
Briefly describe suspected or confirmed release: (including but not fimited to: nature of release, date of release, amount
❑ GPS
of release, amount of free product present and recovery efforts, initial responses conducted, impacts to race tors
❑ Topographic map
\AK^ \,<�\ ( �\`,� `\`
y
i ;\` �1 a�A _ �\ �� _
❑ GIS Address matching
❑ Other
❑ Unknown
Describe location:
csasSl..M ��
c + ! \ (
Iz.43 �� Q GR)
.� •.hs
HOW RE EASE WAS DISCOV RED (Release Code)
(Check one)
❑ Release Detection Equipment or Methods U Visual/Odor Cl Groundwater Contamination
❑ During UST Closure/Removal U Water ,n Tank ❑ Surface Water Contamination
❑ Property Transfer ❑ Water Supply Well Contamination Other (specify)
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Chock one to indicate primary (Check one to indicate primaty (Chock one) (Check one to indicate primary product type
source) cause) released)
'T�
Tank ❑ Spill � Petrcleum ❑ Gasoline/ Diesell ❑ DieselNeg. Oil
"� Kerosene Blend
❑ 7[L. ❑ Piping Overfill U Non-Pelroloum Hosting Oil ❑ Vegetable Oil 100%
❑ Dispenser ❑ Corrosion U Both ❑ Other Petroleum ❑ E10 - E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products ❑ E21 - E84
Cl
Damage Location Motals
❑ Delivery Problem ❑ E85 - E99
❑ Install Problem (Chock one) ❑ Other Inorganics
❑ Other ❑ Other Organics ❑ Ethanol 100%
r l ❑ Other Facility
❑ Unknown � ❑ E01 - E09
iy y Unknown Residence
Definitions presented on reverse Definitions presented on rovers& ❑ Other
Ownership
1. Municipal 2. Military 3. Unknown Private 5. Federal 6. County 7. Slate
Type -\
1. Publicc Service 2. Agricultural 3- esltlentia 4. EducatioNRelig. 5. industrial 6. Commercial 1. Mining
1. Public
UST Form 61 (02/08)
C�Ge�c�e0

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1.
Yes 2. No rUn own
Number of Water Supply Wells Affected ___-------- ____
Water Supply Wells Contaminated: (Include
Users Names, Addresses and Phone Numbers. Attach additional sheet it necessary)
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST OperatorlCompany
Addross
City
late
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
t Li
Ad dress
1013 8�x
City
State
Zip Code
Telephone Num,per
V\Ao" N ' ,r
2'70310
My WP
Draw Sketch of Area (showing two major road intersections) or Attach Map
f?1c +moo to fiJi < ,7
3-�
10
[Peraon Reporting Incident
Company p \
Telephone Number
Cyr S� Vr—�
Address l.
Data 717
UST Form 61 (02108) Ch a��6\(C. _ Papa 2 of 2
Definitions of Sources 2�l`
Tank: means the tank that stores the product and is pan of the underground storage tank system
Piping: means the piping and connectors running front the tank or submersible turbine pump to the dispenser or other end -use equipment ( Vent, vapor recovery, or fill
lines are excluded.)
Dispenser includes the dispenser and the equipment used to connect the dispenser hi the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the lank sump), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the lank. (Typienl causer associated with this source are Npilis and uvcrrillx l
Other: serves as the option to use when the release source is known but dues not tit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been detennincd
Definitions of Causes
Spill: use this cause when a spill occurs (e.g., when die delivery hose is diseomicded tram the lank fill pipe or when the nuzzle is removed from the dispenser)
Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut off at the dispenser)
Physical or Mechanical Damage. use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose finings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is detennined it) have occurred slwcifically because the UST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been deterniined

PO Box 681016
Charlotte, NC 28216
Phone: [phone]
Fax: [phone]
www,cert-Lisa.com
Underground Storage Tank Inspection
3520 Draper Ave., Charlotte, NC
3/9/18
Residence
3520 Draper Ave.
Charlotte, NC
Subject: Home Heating Oil Underground Storage Tank (UST) Inspection
The inspection of an underground storage tank (UST), at the above address was completed on
2/26/18. Facing the house from the street, the tank is located under the house (in the living room
area), accessed through a crawl space door, located in the rear of the house. It is 7 feet off the
structure into the crawl space. The tank appears to be a 550 gallon home heating oil tank. It is 5 '/2
feet to the bottom of the tank from the land surface. The tank was found to be empty.
One soil boring was taken on the side of the tank from inside the house (see photo). The field soil
sample was taken from a depth of 7 feet. The field test result, with the Photoionization Detector
(PID), was 140 PPM (Parts Per Million) Volatile Organic Content (VOC). The field test result
appears to be above the Division of Waste Management, UST Section, North Carolina
Department of Environmental Quality action level of 50 PPM for GRO and 100 PPM for DRO
(gasoline and diesel). This indicates that soil contamination is present at the sample location.
Additionally, a soil sample was taken to the laboratory for analysis. CERT instructed the
laboratory to analyze the soil sample for Total Petroleum Hydrocarbons (TPH) by EPA
GRO/DRO Method. The NCDEQ requires sample preparation Method GRO when analyzing for
low to medium boiling point fuels which include gasoline and gasohol. Sample preparation
method DRO is required when analyzing for high boiling point fuels such as jet fuels, home
heating oil, kerosene, fuel oil #2 and diesel. The laboratory findings are reported as parts per
million (PPM) TPH.
TABLE 1
LABORATORY RESULTS
TPH GRO/DRO PID (VOC)
PPM PPM
Sample # 1 91.6/6530 140
Analytical results for soil sample: Field analysis indicated that the sample location was suspect
with regards to petroleum contamination. The laboratory analysis confirmed that the soil was
impacted under the underground storage tank. The soil sample was analyzed for EPA GRO/DRO.
The GRO/DRO results were above the Minimum Quantification Limits (PPM) Total Petroleum
Hydrocarbons.

The Division of Waste Management, UST Section, North Carolina Department of Environmental
Quality action levels are 50 PPM for GRO and 100 PPM for DRO (gasoline and diesel).
Laboratory results confirm that contaminated soil is present under the tank location.
It is recommended that the tank owner submit a 24-Hour Release and UST Leak Reporting Form
(UST-61) be sent to NCDEQ as required by State regulation (CERT can assist with this form).
The environmental activities, described above, in no way represent a complete environmental
assessment, only determining that contaminated soil is present at the sample location described
above. This process has been initiated at the request of the UST representative. Please retain this
report for your records.
Regards,
Stephen M. Hamilton
Consultant
SMH/jh
2

% e-11t$4 i S. o .
Technical Report for
Spectrum Environmental
Residence; 3520 Draper Ave, Charlotte, NC
SGS Job Number: FA52119
Sampling Date: 02/26/18
Report to:
Spectrum Nationwide
PO Box 790541
Charlotte, NC 28206
[e-mail]
ATTN: Steve Hamilton
Total number of pages in report: i.
.S� I`ccR�O .
3 E
Test results contained within this data package meet the requirements Caitlin Brice, M.S.
of the National Environmental Laboratory Accreditation Program General Manager
and/or state specific certification programs as applicable.
Client Service contact: Muna Mohammed 407-425-6700
Certifications: FL(E83510), LA(03051), KS(E-10327), IL(200063), NC(573), NJ(FL002), NY(12022), SC(96038001)
DoD ELAP(ANAB L2229), AZ(AZ0806), CA(2937), TX(T104704404), PA(68-03573), VA(460177),
AK, AR, IA, KY, MA, MS, ND, NH, NV, OK, OR, UT, WA, WV
This report shall not be reproduced, except in its entirety, without the written approval of SGS.
Test results relate only to samples analyzed.
SGS North America Inc. 4405 Vineland Road Suite C-15 Orlando, FL 32811 tel: [phone] fax: [phone]

Sections:
Table
Section 1: Sample Summary................................................................................................... 3
Wd
Section 2. Summary of flits .. .. ... .... ... . 4
x°E w ... ........ —......... .a..,,�,a.,
3 _1 FA52119-1: SAMPLE 1............................................................................................... 6
Section4; Misc. Forms............................................................................................................ 8
4.1: Chain of Custody........................................................................................................... 9
Section 5, t1t" Volatiles - QC I)ata Sunimaries................................,a..>.>,...... .............m..a.. 11
5.1: Method Blank Summary................................................................................................ 12
52: Blank Spike Summary................................................................................................... 13
5<: Matrix Spike/Matrix Spike Duplicate Summary........................................................... 14
S,4,,C cpn 6" " /l.tsenli volatiles - ; l t,.. sumniaria ",—.....A„..........>.a.......... 15
6,1. Method Blank Summary................................................................................................ 16
6, : Blank Spike Summary................................................................................................... 17
63 Matrix Spike/Matrix Spike Duplicate Summary........................................................... 18
2 y 1.6'

SGS North America Inc.
Sample Summary
Spectrum Environmental
Job No: FA52119
Residence; 3520 Draper Ave, Charlotte, NC
Sample Collected Matrix Client
Number Date Time By Received Code Type Sample ID
FA52119-1 02/26/18 11:00 SH 03/01/18 SO Soil
SAMPLE 1
Soil samples reported on a dry weight basis unless otherwise indicated on result page.
3ofI.E.

Summary of Hits Page 1 of 1
Job Number:
FA52119
Account:
Spectrum Environmental
Project:
Residence; 3520 Draper Ave, Charlotte, NC
Collected:
02/26/18
Lab Sample ID Client Sample ID Result/
Analyte Qual RL MDL Units Method
FA52119-1 SAMPLE 1
TPH-GRO (C6-C10) 91.6 56 28 mg/kg SW846 8015C
TPH (C10-C28) 6530 1200 590 mg/kg SW846 8015C
Of 3
"?I1a

Report of Analysis
5 of 18

SGS North America Inc.
Report of Analysis
Client Sample ID: SAMPLE 1
Lab Sample ID: FA52119-1 Date Sampled: 02/26/18
Matrix: SO - Soil Date Received: 03/01/18
Method: SW846 8015C Percent Solids: 83.9
Project: Residence; 3520 Draper Ave, Charlotte, NC
Page Iof1
File ID DF Analyzed By Prep Date Prep Batch Analytical Batch
Run #1 CD149569.D 1 03/05/18 16:35 EG n/a n/a GCD6250
Run #2
Initial Weight Final Volume Methanol Aliquot
Run #1 6.49 g 5.0 ml 10.0 ul
Run #2
CAS No.
Compound
TPH-GRO (C6-C10)
CAS No.
Surrogate Recoveries
460-00-4
4-Bromofluorobenzene
98-08-8
aaa-Trifluorotoluene
Result
RL MDL Units Q
91.6
56 28 mg/kg
Run# 1
Run# 2 Limits
86%
56-149%
72%
66-132%
ND = Not detected MDL = Method Detection Limit j = Indicates an estimated value
RL = Reporting Limit B = Indicates analyte found in associated method blank
E = Indicates value exceeds calibration range N = Indicates presumptive evidence of a compound
6 of 18
�A52,,a

SGS North America Inc.
Report of Analysis
Client Sample ID: SAMPLE 1
Lab Sample ID: FA52119-1 Date Sampled: 02/26/18
Matrix: SO -Soil Date Received: 03/01/18
Method: SW846 8015C SW846 3546 Percent Solids: 83.9
Project: Residence; 3520 Draper Ave, Charlotte, NC
Page 1 of 1
File ID DF Analyzed By Prep Date Prep Batch Analytical Batch
Run #1 WW15096.D 200 03/09/18 00:25 NJ 03/08/18 12:20 OP69061 GWW610
Run #2
Initial Weight Final Volume
Run #1 20.1 g 1.0 ml
Run #2
CAS No. Compound
TPH (C10-C28)
CAS No. Surrogate Recoveries
84-15-1 o-Terphenyl
(a) Outside control limits due to dilution.
Result
RL MDL Units Q
6530
1200 590 mg/kg
Run# 1
Run# 2 Limits
0% a
56-122%
ND = Not detected MDL = Method Detection Limit J = Indicates an estimated value
RL = Reporting Limit B = Indicates analyte found in associated method blank
E = Indicates value exceeds calibration range N = Indicates presumptive evidence of a compound

Misc. Forms
Custody Documents and Other Forms
Includes the following where applicable:
• Chain of Custody
J
-1,,..,-`.`i

Accutest Laboratories Southeast � •�� Chain of Custody FA5211q
�ACCUTEST 4405Vineland Road, Suite C-15 Orlando,Fl32811 ACCUtB5tJ08# PAGE l OF I
LABORATORIES TEL. [phone] • FAX: [phone]
www.accutest.com
cCuteSt Cluole
Client I Reporting nformation Project Information
Analydcal Information
I Matnx Codes
Com any Name G -
PrpjW Name: \ C ,(2�
`
DW - aNldng Weter
GWWW-Netter
sw. - surtece water
L- ud+
9L -.011Sludge
a•al
Lro - aher Liquid
AIR -Air
�aWoe01d
IMF ONLY
Address
S
Sue
tfeel �C O `l
J
c t, state L Z1
Stela
a Y
I'Mad Contacts +nail
R.I.0 9
PfpneN .1-" L
lNarne le)(Ptlnte�
FazB
$emPlerls
\ y-M r Vet
CI urchase Orft9
Acatan
sa N
Field ID / Point of Collection
sAvPLEn
unrnu
TOTAL
or
€
1
-US
f
5 tr
TURNAROUND TIME Business Days)
Data
Deliverable
Ourmanion
Cornmenls/Remarks
❑ 10 Days Standard Approved By: I Rush Code
❑ 7 Day RUSH
5 Day RUSH -- _—
3 Day EMERGENCY
❑ 2 Day EMERGENCY _
❑ t Day EMERGENCY _
❑ OTHER
Emergency o Rush T/A Data Available VIA Email or Lablink /CQ �
COMMERCIAL "A" (RESULTS ONLY)
COMMEqRCpIALL"B" (RESULTACI OUTC i T
REDT1 Ili 2&0 QUEEN C t T Y DR
FULTi IEPA LEVEGL T NC
�EDD'S\V
4 Ale
SannoIa
Custodvt be documenteAbelow
each m'
i:Iudino courier delive
ReI 'sh by r:
1
ate Time:
a1Z g 2
By:
by :
3
Dai itme:
27 %y✓G
Received By:
4 A 1N
Relinquishe
5
a q'Time:
C !� B
R ived B :
�P
Relinquished
7`
ate Tme:
Recel By p
B b
Lab Use Only'. Cust Seal in Place: Y IN Temp Blank Provided: Y IN Preserved where Applicable: Y N Total # of Coolers: Cooer Temperatures Isius: , 0
of z

SGS Sample Receipt Summary
Job Number: FA52119 Client: CERT Project: RESIDENCE
Date / Time Received: 3/1/2018 1:45:00 PM Delivery Method: FED EX Airbill #'s: 1015906964210003281100808776151445
Therm ID: IR 1; Therm CF: 0.4; #of Coolers: 1
Cooler Temps (Raw Measured) °C: Cooler 1: (3.6);
Cooler Temps (Corrected) °C: Cooler 1: (4.0);
Cooler Information
Y or N
Sample Information
Y or
N
N/A
1. Custody Seals Present
W ❑
1. Sample labels present on bottles
V
❑
2. Custody Seals Intact
V ❑
2. Samples preserved properly
d❑
❑
3. Temp criteria achieved
❑o ❑
3. Sufficient volume/containers recvd for analysis:
d❑
❑
4. Cooler temp verification
IR Gun
4. Condition of sample
Intac
5. Cooler media
Ice(Bag)
5. Sample recvd within HT
❑d
❑
6. Dates/Times/IDs on COC match Sample Label
Q
❑
Trio Blank Information
Y or N
N/A
7. VOCs have headspace
❑
❑
❑,i
1. Trip Blank present / cooler
❑ ❑
❑d
8. Bottles received for unspecified tests
❑
❑J
2. Trip Blank listed on COC
❑ ❑
❑d
9. Compositing instructions clear
❑
❑
❑d
W or S
N/A
10. Voa Soil Kits/Jars received past 48hrs?
❑
❑
❑d
11. % Solids Jar received?
❑J
❑
❑
3. Type Of TB Received
❑ ❑
d❑
12. Residual Chlorine Present?
❑
❑
W
Misc. Information
Number of Encores: 25-Gram 5-Gram Number of 5035 Field Kits: 1 Number of Lab Filtered Metals:
Test Strip Lot #s: pH 0-3 230315 pH 10-12 219813A Other: (Specify)
Residual Chlorine Test Strip Lot #:
;omments SOIL IS MATRIX. NOT ON COC.
shoot Rev. Date 0524/17 Technician: SHAYLAP Date: 3/1/2018 1:45:00 PM Reviewer: P.H Date: 3/1/2018
]"A521 19., of Custody
of 18

Section 5
GC Volatiles
QC Data Summaries
Includes the following where applicable:
• Method Blank Summaries
• Blank Spike Summaries
• Matrix Spike and Duplicate Summaries

Method Blank Summary
Job Number: FA52119
Account: SPECNCC Spectrum Environmental
Project: Residence; 3520 Draper Ave, Charlotte, NC
Page 1 of 1
Sample
File ID
DF
Analyzed
By
Prep Date
Prep Batch
Analytical Batch
GCD6250-MB
CD149567.1)
1
03/05/18
EG
n/a
n/a
GCD6250
The QC reported here applies to the following samples:
FA52119-1
CAS No. Compound Result RL
TPH-GRO (C6-C10) ND 5.0
Method: SW846 8015C
MDL Units Q
2.5 mg/kg
CAS No. Surrogate Recoveries Limits
460-00-4 4-Bromofluorobenzene 88% 56-149%
98-08-8 aaa-Trifluorotoluene 74% 66-132%
2-of'
A521 a

Blank Spike Summary
Job Number: FA52119
Account: SPECNCC Spectrum Environmental
Project: Residence; 3520 Draper Ave, Charlotte, NC
Page 1 of 1
Sample
File ID
DF
Analyzed
By
Prep Date
Prep Batch
Analytical Batch
GCD6250-BS
CD149566.1)
1
03/05/18
EG
n/a
n/a
GCD6250
The QC reported here applies to the following samples:
FA52119-1
CAS No. Compound
TPH-GRO (C6-C10)
CAS No.
Surrogate Recoveries
460-00-4
4-Bromofluorobenzene
98-08-8
aaa-Trifluorotoluene
* = Outside of Control Limits.
Spike BSP BSP
mg/kg mg/kg % Limits
20 22.0 110 74-128
BSP Limits
88% 56-149%
88% 66-132%
Method: SW846 8015C
Y,.

Matrix Spike/Matrix Spike Duplicate Summary Page 1 of 1
Job Number: FA52119
Account: SPECNCC Spectrum Environmental
Project: Residence; 3520 Draper Ave, Charlotte, NC
Sample
File ID
DF
Analyzed
By
Prep Date
Prep Batch
Analytical Batch
FA52180-1MS
CD149573.1)
1
03/05/18
EG
n/a
n/a
GCD6250
FA52180-1MSD
CD149574.1)
1
03/05/18
EG
n/a
n/a
GCD6250
FA52180-1
CD149568.1)
1
03/05/18
EG
n/a
n/a
GCD6250
The QC reported here applies to the following samples: Method: SW846 8015C
FA52119-1
FA52180-1 Spike MS MS Spike MSD MSD Limits
CAS No. Compound mg/kg Q mg/kg mg/kg % mg/kg mg/kg % RPD Rec/RPD
TPH-GRO (C6-C10) 7.3 U 29.2 33.6 115 29.2 33.5 115 0 74-128/17
CAS No.
Surrogate Recoveries
MS
MSD
FA52180-1
Limits
460-00-4
4-Bromofluorobenzene
92%
94%
86%
56-149%
98-08-8
aaa-Trifluorotoluene
91%
89%
74%
66-132%
* = Outside of Control Limits.

QC Data Summaries
Includes the following where applicable:
• Method Blank Summaries
• Blank Spike Summaries
• Matrix Spike and Duplicate Summaries
5of1

Method Blank Summary
Job Number: FA52119
Account: SPECNCC Spectrum Environmental
Project: Residence; 3520 Draper Ave, Charlotte, NC
Page 1 of 1
Sample
File ID
DF
Analyzed
By
Prep Date
Prep Batch
Analytical Batch
OP69061-MB
WW15095.D
1
03/08/18
NJ
03/08/18
OP69061
GWW610
The QC reported here applies to the following samples: Method: SW846 8015C
FA52119-1
CAS No. Compound
TPH (C10-C28)
CAS No. Surrogate Recoveries
84-15-1 o-Terphenyl
Result RL MDL Units Q
ND 5.0 2.5 mg/kg
Limits
73% 56-122%

Blank Spike Summary
Job Number: FA52119
Account: SPECNCC Spectrum Environmental
Project: Residence; 3520 Draper Ave, Charlotte, NC
Page 1 of 1
Sample File ID DF Analyzed By Prep Date Prep Batch Analytical Batch
OP69061-BS WW15094.D 1 03/08/18 NJ 03/08/18 OP69061 GWW610
The QC reported here applies to the following samples:
FA52119-1
CAS No. Compound
TPH (C10-C28)
CAS No. Surrogate Recoveries
84-15-1 o-Terphenyl
* = Outside of Control Limits.
Spike BSP BSP
mg/kg mg/kg % Limits
50 43.3 87 62-116
BSP Limits
82% 56-122%
Method: SW846 8015C
P
't ' of

Matrix Spike/Matrix Spike Duplicate Summary Page 1 of 1
Job Number: FA52119
Account: SPECNCC Spectrum Environmental
Project: Residence; 3520 Draper Ave, Charlotte, NC
Sample
File ID DF
Analyzed
By
Prep Date
Prep Batch
Analytical Batch
OP69061-MS
WW15100.D 1
03/09/18
NJ
03/08/18
OP69061
GWW610
OP69061-MSD
WW15101.D 1
03/09/18
NJ
03/08/18
OP69061
GWW610
FA52180-1
WW15099.D 1
03/09/18
NJ
03/08/18
OP69061
GWW610
The QC reported here applies to the following samples: Method: SW846 8015C
FA52119-1
FA52180-1 Spike MS MS Spike MSD MSD Limits
CAS No. Compound mg/kg Q mg/kg mg/kg % mg/kg mg/kg % RPD Rec/RPD
TPH (C10-C28) 6.0 U 60.4 48.3 80 60.1 46.3 77 4 62-116/35
CAS No. Surrogate Recoveries MS MSD FA52180-1 Limits
84-15-1 o-Terphenyl 79% 77% 78% 56-122%
* = Outside of Control Limits.
8 of 13

241 our Release and UST
r
For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from
an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or
in NC suspected release
(DWM USE ONLY)
Suspected Contamination? (YIN) __`j _ __
Facility 10 Number
Incident # Risk (H,I,L,U) _
Confirmed GW Contamination? (Y/N) �
Date Leak Discovered
Received On ___ Received By _-----
Confirmod Soil Contamination ?(Y/N) __ r__
Co o - ercia . ________
Reported by (circJe one): Phone, Fax or Report
Samples Taken?(Y/N) __�_
Rog on -regulated _------- ___
Region
Free Product? (YIN) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: T
•��'
Address: �CU V
County: TgNxz'- �
City/Town: ,
¢
Zip Code: O L©�
Regional Office (circle one): Asheville, ores 'Ile ayetleville,
Raleigh, Washington, Wilmington. Winston-Salem
Latitude (dacJmold.gr ): QLongitudo (nnce„n i„e ,«. yG, r '� r'
Obtained by:
❑ GPS
Briefly describe suspected or confirmed release: (including but not limiled to: nature of rolease, date of release, amount
of release, amount of free product present and recovery ofloris, initial responses conducted, impacts to receptors)
❑ Topographic map
❑ GIs Address matching
❑ Other
❑ Unknown
Describe location:
d. ; ;\` k� d�a �\ �� J 1
c;. r.Z u.�r.� s. ��C.. S c� 2 Q v+
-'X-3 `:i Q Qr 5 3�3 41U
HOW REfEASE WAS DISCOV RED (Release code)
(Chock one)
❑ Release Detection Equipment or Methods ❑ Visual/Odor ❑ Groundwater Contamination
❑ During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination
❑ Property Transfer ❑ Water Supply Well Contamination Other (specify) � 1_ O C 1 1%
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate pnrnary (Chock one) (Check one to indicate primary product type
source) cause) released)
Tank ❑ Spill Petroleum ❑ Gasoline/ Diesel/ ❑ DieselNeg. Oil
Kerosene Blend
❑ Piping ❑ Overfill ❑ Non -Petroleum Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser ❑ Corrosion ❑ Both ❑V Other Petroleum ❑ E 10 — E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑ E21—E84
❑
Damage Location Metals
❑ Delivery Problem (Check one) ❑ Other Inorganics ❑ E85 — E99
❑Install Problem
❑ Other ❑ Other Organics ❑ Ethanol 100%
❑ Other Facility
❑ Unknown ❑ E01 — E09
Unknown Residence
Definitions presented on reverse I Definitions presented on reverse ❑ Other
Ownership
1. Municipal 2. Military 3. Unknown Private 5. Federal 6. County 7. State
Operatlon Type
1. Public Service 2. Agricultural 3..esidential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/08)
rye i m
RECEIVE®
APR 0 4 2018
NC®EQ SIR® UST

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected?
1. Yes 2. No ' own
Number of Water Supply Wells Affected ___�—------- ,___
Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
City
tale
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
hA 0,e'rt\
Address
100 &OL 60
City
',
State
Zip Code
2,7030
Telephone Number
I 37a 17-9.96l0
r
Draw Sketch of Area (showing two major road intersections) or Attach Map
f44t— v 104"1'31 i,'
Person Reporting Incident
Company \
Telephone Number
Title ���
Address
IDale 7
UST Form 61 (02/08) ' Page 2 of 2
Definitions of Sources
Tank: means the tank that stores the product and is part of the underground storage tank system
Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end -use equipment (Vent, vapor recovery, or fill
lines are excluded.)
Dispenser includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the suhmeraihle turbine pump head (typically located in the tank sump), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with thin snuree arc spills and overfills.)
Other: serves as the option to use when the release source is known but does not ail into one of the preceding categories (c.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been detennined
Definitions of Causes
Spill: use this cause when a spill occur (e,g., when We delivery hose is disconnected from the tank Jill pipe or when the nuzzle is removed from the dispenser)
Overfill: use when an overfill occurs (e.g., overfills may occur from the till pipe at the tank or when the nozzle fails to shut off at the dispenser)
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose firings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have uccumd s1wcifictdly twcause the LIST system was not installed properly
Other: use this option when the cause is known but dues not fit into une of the preceding categories (e.g., putting regulated substances into monitoring we)ls)
Unknown: use when the cause has not been detennined